Innovative Service Delivery for Secondary Prevention of PTSD

OIF and OEF service men and women exposed to high levels of violence are at risk for
developing mental health disorders including Post-traumatic Stress Disorder (PTSD) and Major
Depressive Disorder (MDD). Even those with less severe symptoms who fail to meet diagnostic
criteria for a mental health disorder may struggle to return to pre-deployment functioning.
Studies suggest that a significant percentage of veterans may suffer from "subthreshold"
PTSD; although their symptom presentation is less severe, these veterans experience
emotional distress and reduced quality of life.

Given that Veterans Affairs (VA) mental-health service providers are faced with the
important and challenging task of alleviating the emotional suffering of our service men and
women while staying within budget confines, we need effective, practical, evidence-based
treatments that can be delivered in an expedient and cost-effective manner. Thus, the
current project has two primary objectives: 1) to develop, implement, and evaluate a
treatment program (Behavioral Activation and Therapeutic Exposure, BATE) for OIF and OEF
veterans with PTSD symptoms, and 2) to determine whether or not this program delivered via
telepsychology will be as effective as in-person treatment. Secondary objectives include
determining: 1) which treatment modality is more effective in terms of process variables
(e.g., treatment satisfaction, session attendance), 2) which treatment modality is more
cost-effective, and 3) whether treatment effects differ across race and gender. Study
participants will be randomized to two treatment conditions, BATE delivered via
telepsychology (BATE-T) and BATE delivered in-person (BATE-IP).

The current treatment protocol is based on two, research-supported therapeutic rationales,
Behavioral Activation (BA) and Therapeutic Exposure (TE). Briefly, the treatment aims to
increase the participant's engagement in healthy activities (i.e., activities that are
naturally reinforcing and promote the participant's life values) and exposure activities
(i.e., activities that target specific PTSD symptoms such as avoidance and hyperarousal).
Treatment will be implemented in eight, one and half hour sessions. Although research
supports the effectiveness of behavior- and exposure-based treatments for trauma-related
mental health problems, a potential risk for any counseling program that targets avoidance
symptoms is a temporary increase in emotional distress. Therapists will inform participants
that this is a normal "side effect" of treatment. However, over the course of treatment
should a participant's emotional distress rise to a level above what can be handled via
outpatient counseling, the participant will be removed from the study and appropriate
referrals will be made.

The anticipated duration of this study is four years. Based on results of the study, we will
finalize the treatment manual. In terms of clinical applicability, we plan to present study
findings at conferences and disseminate the treatment manual to VA mental health service
providers in approximately four to five years. Study findings will address important gaps in
the PTSD literature, yielding several contributions to the field. First, to the extent that
BATE effectively reduces symptom severity, this investigational treatment may benefit
individual OIF/OEF service men and women by alleviating emotional suffering and improving
quality of life. Second, to the extent that BATE prevents the development of full-blown PTSD
in subclinical military personnel, this investigational treatment may reduce attrition from
the military due to untreated mental health problems. Third, only a small percentage of
those who might benefit from counseling actually seek services due to barriers associated
with traditional service delivery practices such as geographic distance from the VA hospital
and stigma of psychological treatment. Thus, as telemedicine has been shown to circumvent
these barriers to care, the current project has the potential to reach an otherwise
underserved population: subclinical OIF and OEF service men and women who may be reluctant
to seek care. Fourth, to the extent that BATE-T produces results comparable to BATE-IP, this
study may potentially identify a cost-effective alternative to in-person treatment thereby
reducing post-service treatment costs to VA's.

Inclusion Criteria:

- Participants will be OIF/OEF military personnel,

- age 21 and above, and

- with symptoms of posttraumatic stress disorder (PTSD) assigned on the basis of the
Clinician Administered PTSD Scale (CAPS) and PTSD Checklist-Military (PCL-M).

Exclusion Criteria:

- Actively psychotic or demented persons,

- individuals with both suicidal ideation and clear intent, and

- individuals meeting criteria for substance dependence will be excluded from
participation.